I am a relatively new nurse, less than 6 months, and one thing I noticed that I am still really struggling with is IV insertion. I was looking into taking a course offered for nurses at a local university. The summary of the program stated that it was incorporating information from the Infusion Nurses Society 2010 Standards of Practice, instead of the 2016 edition. Does it matter? Does anyone happen to know the differences between the two editions?
I'm a new nurse as well. About 6 months out of orientation. At first it seemed like I wasn't gonna get my 3 checkoffs before finishing a 90 day orientation...
6 months later, people ask me all the time to start IVs. I'm definitely not the best ever but I have practiced and practiced. On my own patients, and on other people's patients. They say "I need an iv in 11" and if at all possible I'll offer to start one.
Practice really does make you better. Also, the tipping point for me was spending a little time with one of our nurses who used to work ICU. I would go with her and watch when she started an iv on one of my patients because I had already struck out twice.
And I agree with previous posters about trying to spend some time in the ED. this is offered at my hospital and worked wonders for one of my computer workers.
Perhaps the most neglected element of starting IVs is ergonomics.
Do yourself a favor and position the patient and yourself so that you're in a comfortable and relaxed position, not hunched over or twisted around. Also consider using towels to prop the patient's arm up to a comfortable angle for you. Often times it's helpful to lower the HOB to 20 degrees or so in order to achieve a comfortable angle.
Thousands of IV starts to my credit and I still take the time to set everything up just so.
Another tip: To help visualize veins, shine a light across the arm to help create a bit of a shadow.
Perhaps the most neglected element of starting IVs is ergonomics.
Do yourself a favor and position the patient and yourself so that you're in a comfortable and relaxed position, not hunched over or twisted around. Also consider using towels to prop the patient's arm up to a comfortable angle for you. Often times it's helpful to lower the HOB to 20 degrees or so in order to achieve a comfortable angle.
Thousands of IV starts to my credit and I still take the time to set everything up just so.
Another tip: To help visualize veins, shine a light across the arm to help create a bit of a shadow.
Just to add another tip, don't be afraid to manipulate the patient's arms a bit because sometimes by pronating or supinating the forearm, you can tease a vein into showing itself. Just a week or so ago I had a patient who had seriously horrible veins near the antecubital fossa. I did a little manipulation and found an angle where a large forearm vein suddenly showed itself and I had a good 10-12 cm of vein to use. The week prior I had another patient with poor access in the usual locations and I found a nice vein running along the ulna (I forget the name of the vessel) and with some repositioning of both me and the patient, I managed to get that one in one stick.
So, my tip is really an expansion on an earlier one: spend lots of time looking at all your options, even in places you might not ordinarily look and you might find a great vein you can stick on your first attempt.
Oh, and I agree about ergonomics. The more comfortable you are and the more comfortable and supported the patient is, the more likely you'll get that stick. I'm also a Paramedic and I'm used to starting IV lines from unusual angles and positions, but if you can at all help it, get comfy and be confident (and sometimes a little aggressive) and go for it.
As you are an IV infusion specialist, you are respected as the expert. However, after ten years in EDs, three of them Level I trauma centers, I can attest that my colleagues, many with more ED experience than I, and I shared all the tricks that we knew to help get that line NOW. The semantics of using the work "slapping" may have sounded too aggressive. A two finger "slap" will suffice.Your points are well taken. It is helpful for anyone, including those learning how to insert IVs, to hear your input.
Personally, I opt for the 1-finger flick.
I won't bow to anyone's expertise unless I see them routinely starting emergent lines on IVDAs, DMs, and CKD patients.
Feet, toes, shins, abdomen, chest, breasts, fingers, and even the palms... all places I've started lines in a pinch.
Sometimes I put two tourniquets on the arm on harder sticks. There's sometimes a great vein on the underside of the forearm no one even looks for, but it's sort of a funny angle and you often need a second person to help hold to get it unless the patient is really good at holding still. Little old ladies with good veins I usually don't tourniquet or they'll blow on me. the interns vein doesn't show up in everyone but I really like it as one of my first choices. I try to avoid the hands because they blow a lot or lose their ability to give blood frequently and most my ER patients need repeat labs (troponin or usually the lab calls saying one specimen hemolyzed). Plus I think they hurt most times more than forearm or AC. If it pulsates don't poke .
as everyone else said practice is your best friend. I was on here asking the same question 4 years ago. I still have a rough time with pediatrics, but we all have our strong and weak skills.
People in the ED tend to run for the 20g angiocath. If someone who has been stuck multiple times in triage without success comes back to me, I may go with a 22 and if that doesn't work, a 24g which is enough to get a liter of fluids, pain medicine and nausea. Sometimes you have to be creative. I have put IVs in the shoulders, legs, and breast. Using two tourniquets spaced at least 4 inches apart also helps. Sometimes for very fragile veins you may have to put the tourniquet on the upper arm for a vein in the wrist to avoid blowing the vein. I try to keep a distance between the tourniquet and the vein I am sticking. I think officially 6-8 inches is the correct distance. Initially, go for veins that you can palpate. Go in slowly to avoid blowing the vein and to check for valves. Positioning is also important. Make sure you are comfortable before you stick. I am left handed and find it easier to place IVs on people's right arm which is good because most people have better veins on their dominant side especially people with a history of IVDA. Let the patient dangle the arm. Making a fist I finds help to pump up the vein but you want the hand relax before you stick. Also, when a patient tells you they are a "hard stick" don't believe them! Go in with confidence and let yourself make that assessment. Also, don't give into pressure by the patient to stick in the hand or the arm or where to put the tourniquet. This is especially the case with chronic patients. Stick where you see a good vein and feel confident. When you are first learning to put in IVs go for the smaller angiocaths and go for veins you can palpate. Check both arms before deciding where to stick. Once you get the hang of it, you will become better at sticking veins that you can see, even faintly with a light, but not necessarily feel. Lights are great for darker skinned patients. Make sure you anchor the vein well so it doesn't roll. There is no one good way to anchor the vein - it really depends where the vein is. An sometimes you just have to go in blind to the AC and hope you stick something that is not an artery - if ultrasound is not available. Arteries are hard, if you are trying to poke something hard - it is an artery.
Shoulders, legs, and breasts should only be used in an emergency situation and replaced and removed ASAP. Using those veins is just asking for trouble. Our hospital requires a doctors order for those alternate locations. If it's all you can get and they need something right now, it may be necessary, but I don't consider that being creative. I think it's a stop gap measure only and would hope that it's used only as a last resort
Specializes in Flight Nursing, Emergency, Forensics, SANE, Trauma.
More recently, instead of repetitively poking people for over used spots in the ACs, forearms, wrists, or hands, if I know I can get an upper arm or hell a shoulder IV-- I'll do it. I prefer to have my patients comfortable rather than be turned into pin cushions because of what is considered "normal." If they're sick and need medications and fluids now-- they're getting the first I can get. Additionally, I may be able to get that 22 in the hand but the 18 in the bicep will do them a lot better in fluid resuscitation or if they need IV contrast.
Upper arm or even shoulder is not leg or breast. I do shoulder if that's all I can get temporarily and upper arm is fine. My point is that the alternate site IV should not remain. You do not want an infiltration in the EJ, breast or leg. Much more risk of complications. The ER is a unique place and the focus is on getting an IV and labs wherever you can. It's an emergent situation. I get that. The OP wanted tips on starting IV's and those tips, in my opinion, should not include use of creative sites as a matter of course.
Specializes in Flight Nursing, Emergency, Forensics, SANE, Trauma.
My point in "being creative" was to educate that sometimes repetitive poking in traditional places isn't always ideal. I wasn't criticizing your statement (I didn't even read yours before posting mine), that they shouldn't remain, so please don't become argumentative about my particular post.
I've started IVs in foreheads, breasts, abdomens, feet, and knees. It's important to do the "long lasting" ones, but is equally as important to know how to start them elsewhere in the event you can't get something in the arms and need something right away.
The concepts remain the same no matter where you go-- stabilize the vein, approach at an angle, flatten when you get flash and advance another mm or two, and slide in the sheath.
I won't bow to anyone's expertise unless I see them routinely starting emergent lines on IVDAs, DMs, and CKD patients.
Feet, toes, shins, abdomen, chest, breasts, fingers, and even the palms... all places I've started lines in a pinch.
So, the expertise of a Vascular Access Specialist isn't recognized by you, unless you see them place lines in areas that shouldn't be used in the first place???
JUST because you CAN place an IV catheter in these non-traditional places, doesn't mean that those places are acceptable to cannulate, and wisdom of anatomy says that these are dangerous for the patient. So, unless I place an IV in a dangerous spot, then I am not getting your respect.. Hmm.
In the case of a dying patient, I understand the need to get an IV in, but why use a vein that is NOT appropriate when you can differ to a specialist to place one with US, and one that wouldn't carry the same risks for your pt?
" An sometimes you just have to go in blind to the AC and hope you stick something that is not an artery - if ultrasound is not available. Arteries are hard, if you are trying to poke something hard - it is an artery."
NEVER do a blind probe!! Don't you realize that that is the number one way to cause your patient nerve damage. RSD, Causalgia are real complications of this damage.
And Veins do become hardened and sclerosed and should not be cannulated.
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Kharma711
34 Posts
I'm a new nurse as well. About 6 months out of orientation. At first it seemed like I wasn't gonna get my 3 checkoffs before finishing a 90 day orientation...
6 months later, people ask me all the time to start IVs. I'm definitely not the best ever but I have practiced and practiced. On my own patients, and on other people's patients. They say "I need an iv in 11" and if at all possible I'll offer to start one.
Practice really does make you better. Also, the tipping point for me was spending a little time with one of our nurses who used to work ICU. I would go with her and watch when she started an iv on one of my patients because I had already struck out twice.
And I agree with previous posters about trying to spend some time in the ED. this is offered at my hospital and worked wonders for one of my computer workers.
Good luck and happy sticking!